Navigating the 2015 PQRS Requirements

By now, I’m sure you’ve heard terms such as PQRS, meaningful use, EHR incentives, and the like circulating throughout our medical world. Have you deciphered what each of them mean? How about how to avoid the penalties associated with these programs? At the end of 2014, Dr. Courtney Dryer gave new grads a look into meaningful use (MU). Check out her article here.

Now it’s time to think about PQRS.

CMS, the Centers for Medicare and Medicaid Services, is the organization in charge of the Physician Quality Reporting System (PQRS), and defines the program as such:

PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs).

Unfortunately, as of 2015, the incentive portion has been discontinued and only the negative payment adjustments remain. This means that, if you do not meet 2015 PQRS requirements, you will be subject to a 2% deduction in your Medicare reimbursements for the 2017 filing year. Previously, a physician was required to meet one set of parameters to avoid the penalty and were rewarded through incentives if they met a set number of additional quality measures. The latter is no longer true.

In order for a doctor to avoid the penalty in 2015, he or she will have to successfully report 9 PQRS measures covering at least 3 NQS domains and 1 cross-cutting measure. I know this sounds like I’m speaking Greek, but it will make much more sense soon.

So….how are you supposed to achieve this goal and avoid the penalty? Good question. Below I’ll walk you through 4steps to get you on the right track.

Step 1: Review the measure options

There are over 250 different measures sorted into 6 different groups–called NQS domains–that can be reported in 2015….overwhelming, I know. However, only a handful of these pertain to eye related conditions. There are six eye measures that optometrists should plan to attempt to achieve:

CMS expects optometrists to complete these 6 measures as a group. This means that if you report on 5 of the 6 and leave off the last measure, CMS will validate that the physician had no way of reporting the 6th. If they find that you could have reported the omitted measure on even one patient, you will automatically fail your PQRS submission and incur the penalty.

Outside of the eye measures, you must also complete 3 others. You want to make sure that one of these is considered a cross-cutting measure and that you have picked measures from at least 3 different NQS groups. The entire list of measures can be found on the CMS website. Click on the 2015 measures list, and open the excel spreadsheet they’ve provided. This document will list each of the measures and give you the description, NQS domain, and whether or not it is considered cross-cutting for each option. I have also provided a shortened excel sheet at the end of this post that will give you information on the 6 eye measures, as well as a handful of other choices I’d recommend considering. All cross-cutting options are highlighted in light blue within this tool.

Step 2: Decide on which measures you’ll report

Once you’ve thoroughly reviewed the different measure options, you’ll want to decide which ones you’ll be attempting for the year. Some will require making sure certain things are included in your workups. For example, to meet PQRS measure 317 (Preventative Care and Screening for High Blood Pressure and Follow-up Documented), you will need to take blood pressure readings on all patients 18 years old and older. Then you will counsel them according to your findings. Many clinics only take readings on at risk patients, symptomatic patients, or those previously diagnosed with hypertension. Therefore, you would need to adapt your work-up to make sure to have this reading done on all eligible patients. Becoming very familiar with the requirements of the measures you’ve chosen will help both you and your staff make sure you complete them successfully.

As stated previously, you must choose 9 measures from at least 3 different NQS domains and 1 cross-cutting option. Pay particular attention to these categories when you select your choices. If you do not report on 9 measures or do not span 3 domains, Medicare will perform Measure-Applicability Validation (MAV). Basically, this means that CMS will investigate to determine whether or not you could have reported on more measures or more domains. If they find that you indeed could have, but did not, you will be considered to have unsuccessfully reported for the year. More on MAV can be found here.

Step 3: Choose a reporting method

CMS requires that all measures are reported in the same method. There are six different options, but the three most common are:

Claims based reporting – you will submit a code, much like a CPT code, that will identify that a measure was applied to a patient.

EHR reporting – data is taken directly from your EHR system

Registry reporting – the physician registers with a registry who will collect the data and submit it to CMS

Unfortunately, 3 of the 6 eye group measures are not eligible to be submitted through EHR reporting. Therefore, optometrists will not be able to report through this method in 2015. Some registries are helpful, but my recommendation is to use claims-based reporting. The applicable codes can be added to your superbills and circled to remind you to report these when you file claims or many EHR systems can be set up to prompt you for these codes while you are doing your normal billing.

The codes associated with each measure can be found within the full measure description, again on the CMSwebsite. Under “Resources for 2015 PQRS Measures,” you will want to select the “2015 PQRS Individual Claims Registry Measure Specification Supporting Documents,” then click “agree” on the license agreement screen. A .zip drive will download, and you should open the first PDF, Claims Registry. This large guide will break down each PQRS measure, explain which patients qualify for reporting, and detail which codes to use to represent whether or not the patient successfully meets the measure requirements. They are in order by PQRS number, so it is important to write down which ones you are attempting to fulfill when you select your measures.

Step 4: Get started

The 2015 reporting year is supposed to representative of the entire Jan 1-Dec 31 time period, so it’s important to get started as soon as possible. It’s not too late. Just remember to follow these steps and use the tips below so that you can more accurately report for the year.

Congratulations! You’re ready to start successfully reporting your 2015 PQRS measures! Below you’ll find some additional tips and resources to help answer any remaining questions you may have. Good luck new grads!!!

The CMS website is going to be your best tool going forward. It has a wealth of information, so be sure to take a look before you get started. You’ll want to pay particular attention to the “Measures Codes” tab on the left side of the screen. This is where you’ll find the PDF and excel spreadsheet mentioned earlier, as well as an Implementation Guide that is extremely informational. I’ve included a direct link to the guide below.

Successful reporting of a measure is considered50%. This means that only half of the eligible patients must have met the requirements of the measure for you to get credit for the measure. For example, let’s assume you have chosen to report on PQRS 140, which deals with counseling for AMD patients. If you had 100 patients 50 years old or older with a diagnosis of AMD in 2015, you would have to have counseled 50 or more of them on the benefits and risks of AREDS 2 supplements in order to get credit for this measure.

Don’t get overwhelmed.The biggest key to reporting is knowing the ins-and-outs of the measures you’ve chosen so that you can identify which patients to report the certain codes on and make sure your exams have the proper components.

For some physicians, the work is not worth the reward….or I guess I should say not worth avoiding the penalty. You will only be docked 2% of your Medicare reimbursements 2 years after the reporting period, and the penalty only applies to one year. In other words, if you fail in 2015, your penalty will be applied by reducing your Medicare reimbursements by 2% in 2017. 2018 will depend on whether or not you were successful in 2016. So, if you do not have a high number of Medicare claims, you may find that taking the reduction won’t make a significant difference in your practice’s bottom line.

I’d strongly recommend calculating your Medicare reimbursements for 2014, then taking 2% of that number. If that amount is somewhat low, you may decide PQRS isn’t worth your time.

Make sure you have 9 measures, 3 NQS domains, and 1 cross-cutting measure. You don’t want to have to deal with the validation process if you can avoid it.

Keep up with the changes to the program each year.There are constantly added or deleted measures and adjustments to the requirements to achieve successful reporting. Don’t assume what you do for 2015 will be the same in 2016.

About Patricia Fulmer O.D.

Patricia is a 2012 graduate of The University of Alabama at Birmingham School of Optometry and former AOSA National Liaison to the AAO. After graduation, she moved to Amarillo, TX, to complete her residency in Ocular Disease and Primary Care at the Thomas E. Creek VA Hospital. Patricia is the current Center Director for VisionAmerica of Huntsville, a co-management practice specializing in secondary and tertiary care, cataract surgery, strabismus, and oculoplastics in Huntsville, AL. She recently earned her Fellowship in the American Academy of Optometry at the 2015 meeting in New Orleans. In her free time, she enjoys traveling, attending concerts, art, and Alabama football.